Michel R. M. San Giorgi

Clinical course of recurrent respiratory papillomatosis: Comparison between aggressiveness of human papillomavirus-6 and human papillomavirus-11

Recurrent respiratory papillomatosis (RRP) is mainly associated with human papillomavirus (HPV)6 or HPV11. The purpose of this study was to compare clinical outcome, aggressiveness, and treatment response between HPV6‐ and HPV11‐associated RRP.

The Association Between Gastroesophageal Reflux Disease and Recurrent Respiratory Papillomatosis: A Systematic Review

Antireflux therapy is incorporated in many treatment protocols for recurrent respiratory papillomatosis (RRP) because gastroesophageal reflux (GERD) is thought to worsen the disease course of RRP. It is unclear if GERD really aggravates the disease course. The aims of this systematic review were to 1) evaluate incidence of GERD among RRP patients and 2) report if GERD changes the clinical course or tissue properties of RRP.

The association between gastroesophageal reflux disease and recurrent respiratory papillomatosis

Antireflux therapy is incorporated in many treatment protocols for recurrent respiratory papillomatosis (RRP) because gastroesophageal reflux (GERD) is thought to worsen the disease course of RRP. It is unclear if GERD really aggravates the disease course. The aims of this systematic review were to 1) evaluate incidence of GERD among RRP patients and 2) report if GERD changes the clinical course or tissue properties of RRP.

Quality and readability assessment of websites related to recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis (RRP) is a rare disease for which a limited number of information sources for patients exist. The role of the Internet in the patient–physician relationship is increasing. More and more patients search for online health information, which should be of good quality and easy readable. The study aim was to investigate the quality and readability of English online health information about RRP.

The clinical course of recurrent respiratory papillomatosis after the use of cidofovir is influenced by multiple factors.

With great interest we read the article of Grasso et al. [1] on the use of cidofovir in treatment of recurrent respiratory papillomatosis (RRP). The article discusses the positive influence regarding the number of interventions needed to eradicate papillomas after repeated administration of cidofovir. Although we have applied cidofovir for many years [2] and its long-term safety has been shown [3], we would like to emphasize that treatment effect of cidofovir should be handled with great care. In an article published online shortly after acceptation of the article of Grasso et al. we showed that the clinical course of RRP is influenced by multiple factors [4]. Changes in the clinical course of RRP should therefore only be considered as true treatment effect if these factors are taken into consideration or are corrected for. The natural clinical course of RRP shows a decrease of aggressiveness trough the course of the disease [4]. Furthermore, age of onset of the disease in combination with the HPV type (HPV6 or HPV11) are of great importance for the course of the disease [4]. The younger the age of onset, the worse the clinical course of the disease will be [4]. Especially younger HPV11 patients experience a more aggressive clinical course in comparison with their HPV6 peers [4]. Gastroesophageal reflux disease and asthma negatively influence the course of RRP [4]. In our opinion, it is advisable to not use the term ‘cure’ or talk of ‘remission’ when the follow-up of patients is only 1-month, as is done in some of the presented patients [1]. In our series of 55 patients it was shown that the disease can recur after 1 week till 34 years after the last surgical intervention [4]. Unfortunately, Grasso et al. [1] fail to give information on duration of the disease before administration of cidofovir, the age of onset, HPV type of all patients, and comorbidity. The true effect of cidofovir is therefore indeterminable. Concluding, it is of utmost importance that future research on treatment effect of any therapy in RRP patients should take into account this multifactorial composition of disease course. All factors mentioned above should be reported and corrected for to protect patients against unnecessary interventions. A multi-institutional randomized controlled trial should be considered to proof the effectiveness of cidofovir.

Recurrent Respiratory Papillomatosis: >2 Entities

To the Editor—With great interest we read the article by Novakovic et al about the incidence of juvenile onset recurrent respiratory papillomatosis (RRP) [1]. The described preventive effect of the quadrivalent human papillomavirus (HPV) vaccine, Gardasil, is promising. In an editorial in the same issue, Donovan and Callander discuss the clinical importance of these results [2]. As residents of a country that unfortunately only provides the bivalent HPV vaccine, Cervarix (which targets HPV types 16 and 18), to adolescent girls, we do not expect any effect on the incidence of RRP induced by HPV types 6 and 11 in our country. We agree with the conclusion of the editorialists that Australia and other high-income countries have an obligation to publish the impact of their vaccination programs, to fight national and personal hesitancy to provide quadrivalent vaccination [2]. However, the editorialists convey an important misconception concerning RRP. Donovan and Callander incorrectly described the disease as having 2 peaks of incidence, one during early childhood and another around 30 years of age [2]. In 2016, we published a cross-sectional distribution analysis of 639 European patients with RRP [3]. The described 2 peaks of incidence were confirmed, but a third peak of incidence was found around the age of 64 years [3]. These results match the characteristics of the HPV infection incidence in the adult population [3]. The group of older patients with RRP is of importance in this context because they might benefit the least from the current prevention programs. We would, therefore, advocate separate analyses of the incidence of RRP in this group. Different preventive measures might be needed to eradicate RRP in older patients. Note

Validation of the Distress Thermometer and Problem List in Patients with Recurrent Respiratory Papillomatosis.

Objective There is no specific clinical tool for physicians to detect psychosocial and physical distress or health care need in patients with recurrent respiratory papillomatosis (RRP). The main aim of this study is to validate the RRP-adapted Distress Thermometer and Problem List (DT&PL). Study Design Prospective cross-sectional questionnaire research. Setting Academic tertiary care medical centers in Groningen, Netherlands, and Helsinki, Finland. Subjects and Methods Ninety-one juvenile- and adult-onset RRP patients participated from the departments of otorhinolaryngology–head and neck surgery of the University Medical Center Groningen, Netherlands, and Helsinki University Hospital, Finland. The Hospital Anxiety and Depression Scale was used as the gold standard. Results A DT cutoff score ≥4 gave the best sensitivity and specificity. Thirty-one percent of patients had significant distress according to the DT cutoff. Significantly more patients with a score above than under the cutoff had a referral wish. The PL appeared to be reliable. Patients’ opinions on the DT&PL were largely favorable. Conclusion The Dutch and Finnish versions of the DT&PL are valid, reliable screening tools for distress in RRP patients.

Quality of Life of Patients With Recurrent Respiratory Papillomatosis

Recurrent respiratory papillomatosis (RRP) is a disease with a high disease burden. Few studies have assessed quality of life (QoL) of RRP patients. This study compares QoL of these patients with controls. Associations between QoL and sociodemographic and illness‐related factors are examined, as is uptake of psychosocial care and speech therapy.

Recurrent Respiratory Papillomatosis and Human Papillomavirus

Recurrent respiratory papillomatosis (RRP) is a disease that is characterized by recurrent growth of exophytic wart-like lesions throughout the respiratory tract. The disease is mainly associated with low-risk human papillomavirus (HPV) types 6 and 11. The distribution of the age of onset of RRP shows three peaks: age 4 years old, age 34, and age 60–64. Patients with RRP generally experience voice problems and without treatment, eventually develop a compromised airway. Owing to the recurrent character of RRP, most patients require repeated surgical interventions to remove the lesions to keep the voice functional and the airway patent. There is currently no cure for RRP. This chapter reviews the etiology, diagnosis, therapeutic options, and prevention of RRP.